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No repeal in 2017: Readers respond

February 6, 2014 at 6:00 am

Austin Frakt

A few readers wrote me in response to a post last week. At issue, it seems, is my assertion that

The best bet for health policy compromise, in my view, is if the GOP sweeps in 2016. It is hard for me to believe they would actually repeal the law [in 2017] in that case without implementing a substantially similar replacement.

Tom Bokuneiwicz begs to differ,

[Republicans] do not want people to have health care unless they can afford it. To them less people buying health care drives prices down—no demand is no supply. They do not see health care as a moral issue (despite their alleged allegiance for the most part to the teachings of Christ). Hence, they will do all they can to limit health care. Forcing the poor to pay more, as they do, is just one clear point. Reducing the Medicaid threshold is another. Health care is a moral issue and until they assert that you should not give them a pass.

Charlene K offered something similar,

Respectfully, I disagree with you that Republicans would replace Obamacare if they won a clean sweep in 2016. All you have to do is look at places like North Carolina, where you can see the effects of Republican rule.

These Republicans are so brazen, they will promise and spin but they will never get around to actually implementing a plan. And I don’t think that the insurance companies would mind – they would have people enrolled and then would be free to kick people off who cost too much money. Sure, they might keep some piecemeal things, like allowing 26 year old people on their parents’ plan, but not much more than that. If they haven’t come up with a viable alternative to Obamacare in 5 years, they won’t get it done. Once you abolish the mandate, the whole thing falls apart. Whatever they put in place, without a mandate, is a joke and will never pass once the CBO ratings come in. We will get the status quo ante.

It’s easy for me to understand why people feel this way, especially when examining states like North Carolina, with Republican-controlled governments that have opted not to expand Medicaid.

But I also understand that a few years is long enough to make a huge difference in what Republicans (and Democrats) may be willing to do. For every North Carolina there’s a Massachusetts, for every Texas there’s a California. To make national law that might satisfy the Red states would enrage the Blue ones. Last I checked, there are Senators and Representatives from all the states; there are very invested and influential stakeholders everywhere; and taking away people’s health insurance makes for very easy and powerful attack ads.

In a few years, Medicaid and exchange-based coverage expansion will be the entrenched status quo in at least half the states, if not more. That’s going to matter. A lot. Unless the Affordable Care Act is a clear disaster almost everywhere, I don’t expect repeal to ever be more than campaign rhetoric or the spin put on a law that also does some significant, similar replacing. And, if the ACA is actually a disaster, not just Republicans should favor repeal.

The best precedent for repeal in health policy is the Medicare Catastrophic Coverage Act, passed in 1988 and repealed in 1989. That repeal was swift and bipartisan. The “new status quo” had no time to entrench. The ACA is clearly different. There’s no chance at swift repeal, and certainly not with bipartisan support. So long as the ACA doesn’t destroy itself, repeal (without similar replacement) in 2017 that upsets health insurance in half or more states seems politically impossible. The law will rise or fall largely on its merits, with a strong status quo tail wind.